Sheer Number of CMS Contractor Entities Causes Confusion

CMS Creates Resources Defining 'CERT,' 'PERM,' Others

September 22, 2011 11:50 am News Staff

What do the acronyms and initialisms CERT, PERM, PSCs, MICs and ZPICs all have in common?

All are entities or programs either created and supported by CMS or contracted out by CMS to help find and fix underpayments, overpayments or outright fraud in government health care programs such as Medicare, Medicaid and the Children's Health Insurance Program, or CHIP.

In fact, the fraud-fighting functions of CMS have become so immense that the agency recently released an MLN Matters special article(www.cms.gov) devoted almost entirely to listing and describing for physicians the various entities that "may contact them with questions and requests for medical records, documentation or other information."

According to the article, "CMS recognizes that shifts in contracting entities due to recent Medicare contracting reform may be confusing." The agency explains the function of each entity, why someone from that group may be contacting the physician and what materials the requesting entity may ask to see.

To help quash any confusion that may arise in physician practices when outside inquiries are made, CMS also created a downloadable quick-reference guide, "Contractor Entities at a Glance: Who May Contact You About Specific CMS Activities(www.cms.gov)," that describes the many contractor programs CMS utilizes and their acronyms and initialisms. For example, CMS uses

  • the comprehensive error rate testing review contractor, or CERT, program to measure improper payments in the Medicare fee-for-service program;
  • payment error rate measurement, or PERM, contractors to measure improper payments in the Medicaid and CHIP programs;
  • program safeguard contractors, or PSCs, to oversee the zone program integrity contractors, or ZPICs, with whom CMS contracts to identify cases of suspected fraud and take appropriate action; and
  • Medicaid integrity contractors, or MICs, to conduct audit-related activities for Medicaid.

CMS urges physicians to print out the guide and make it available to all office staff who could receive requests from any of the entities listed.

A small portion of the MLN Matters document centers on claims processing contractors, which are described as entities with which CMS contracts to process Medicare claims. Information about the role of the new Medicare administrative contractors, or MACs, and about Medicare contracting reform(www.cms.gov) also is available on the CMS website.

In general, MACs contact physicians to

  • resolve enrollment application issues,
  • provide help on Medicare billing procedures,
  • resolve issues with submitted claims,
  • request medical records related to claims submitted for medical review and
  • recover overpayments on claims previously processed.

MACs also make contact physicians to pay for an approved claim or to explain why a claim was not processed or was denied.


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